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Total Results: 1,785 records

Showing results for "problem".

81. Addressing Problematic Opioid Use in OECD Countries. | PSNet
    psnet.ahrq.gov/issue/addressing-problematic-opioid-use-oecd-countries
    October 14, 2020 - opioid epidemic and suggests that system-focused multisector strategies are required to address the problem

82. Malnutrition in Hospitalized Adults: A Systematic Review. | PSNet
    psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
    December 21, 2022 - in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33573/psn-pdf
    March 15, 2025 - issue was underscored by a 2008 Joint Commission sentinel event alert, which called attention to this problem … emphasis; Vanderbilt University has achieved notable success in this area through identification of problem … prone-score-algorithm-predicting-doctors-risks-formal-patient-complaints-using-routinely https://psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution

84. Systems approach to suicide prevention: strengthening culture, practice, and education. | PSNet
    psnet.ahrq.gov/issue/systems-approach-suicide-prevention-strengthening-culture-practice-and-education
    July 10, 2024 - Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department

85. Alert Fatigue | PSNet
    psnet.ahrq.gov/primer/alert-fatigue
    March 15, 2025 - The problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the … require use of the principles of human factors engineering as well as those of informatics, as the problem … In solving the problem of alert fatigue, health care will need to look to examples from other industries … March 29, 2023 Applying human factors engineering to address the telemetry alarm problem

86. Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level. | PSNet
    psnet.ahrq.gov/issue/beyond-burnout-physician-wellness-hierarchy-designed-prioritize-interventions-systems-level
    July 19, 2023 - Physician burnout is a persistent problem that can have serious effects on safe practice.

87. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. | PSNet
    psnet.ahrq.gov/issue/negative-impact-nurse-physician-disruptive-behavior-patient-safety-review-literature
    August 18, 2021 - reviewed the existing literature on disruptive behavior by physicians, and concluded that while the problem

88. Burnout in the nursing home health care aide: a systematic review. | PSNet
    psnet.ahrq.gov/issue/burnout-nursing-home-health-care-aide-systematic-review
    May 18, 2022 - Burnout is a pervasive problem in health care that can affect clinician performance and patient safety

89. Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review. | PSNet
    psnet.ahrq.gov/issue/challenges-and-opportunities-agency-healthcare-research-and-quality-ahrq-research-summit
    October 04, 2020 - diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem

90. A Transformational Effort on Patient Safety. | PSNet
    psnet.ahrq.gov/issue/transformational-effort-patient-safety
    October 05, 2022 - This report introduces the persistent problem of unsafe care and recommends a federal leadership entity

91. Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet
    psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
    March 16, 2022 - United States Veterans Affairs EHR system problems on medication management , care coordination, and problem

92. 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. | PSNet
    psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
    October 06, 2021 - case study of community pharmacies in England, the authors found that polypharmacy was a pervasive problem

93. The inevitability of physician burnout: implications for interventions. | PSNet
    psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
    April 17, 2024 - The author advocates for a systematic bottom-up approach to address the problem.

94. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
    psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
    April 26, 2023 - He came to the team and said, “I have this problem in the inpatient setting, let’s do something about … Another aspect of the alarm problem is distraction. … Finally, there’s the literature on alarm fatigue, which gets confused with the alarm problem, because … You’re trying to address the problem of severe and sustained events. … monitoring on general care units is the alarm problem .

95. Raising an alarm, doctors fight to yank hospital ICUs into the modern era. | PSNet
    psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era
    February 14, 2024 - The sinks can make the problem worse. … September 1, 2016 Insights into the problem of alarm fatigue with physiologic monitor

96. Did We Forget Something? | PSNet
    psnet.ahrq.gov/web-mm/did-we-forget-something
    April 28, 2021 - decrease in the incidence of foreign bodies left during procedures.( 1 ) However, the true scope of this problem … removed.( 6 ) Surgical teams have used sponge, sharp, and instrument counts as protection against this problem … to human error.( 7 ) Anyone who has ever had to recount a pile of coins will recognize the potential problem … What can be done to prevent this problem? … Retained sponges and instruments remain a disturbingly common problem, and current preventive practices

97. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
    psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
    April 26, 2023 - monitoring on general care units is the alarm problem . … He came to the team and said, “I have this problem in the inpatient setting, let’s do something about … Another aspect of the alarm problem is distraction. … Finally, there’s the literature on alarm fatigue, which gets confused with the alarm problem, because … You’re trying to address the problem of severe and sustained events.

98. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
    psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - Culture change inevitably occurs slowly, through cycles of action and interpretation.( 8 ) Problem solving … A focus on problem solving also reinforces the learning orientation that is core to a culture of safety … while building problem-solving capacity. … Often considered "the problem," resistance may be more productively and accurately viewed as the key … 1, 2013 Perspective How to Identify and Manage Problem

99. Common Formats for Event Reporting - Diagnostic Safety Version 1.0 | PSNet
    psnet.ahrq.gov/issue/common-formats-event-reporting-diagnostic-safety-version-10
    December 24, 2008 - Effective measurement of diagnostic error is essential for understanding the problem and generating

100. Pregnancy-related deaths: saving women’s lives before, during and after delivery. | PSNet
     psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery
     September 07, 2016 - Maternal morbidity and mortality is a worldwide patient safety problem.